It’s done. Congress on April 14 passed and the president signed into law a bill that terminates one of the most egregious and silliest examples of dysfunctional government in recent years—the so-called “sustainable growth rate” (SGR) formula for doctors’ fees under Medicare.
A previous blog explained the background and protracted lead-up to this moment.
First, a round of applause for bipartisan agreement—however obvious it was that had to happen in this case. The vote in the house was 392-37. In the Senate, it was 92-8.
Praise is also in order for enacting two more years of funding for the Children’s Health Insurance Program and $7.2 billion in new funding over two years for community health centers, a program that was expanded under the Affordable Care Act and serves low-income families. There’s also welcome help for low-income Medicare beneficiaries and rural hospitals.
But the main thrust of the law is to kill one (failed) program that adjusted doctors’ fees under Medicare and create a new and hopefully better one.
Continue reading “The Big Fix. Medicare Doc Pay Enters a New Era”
Filed Under: THCB
Tagged: Doc Fix, Medicare, MIPS, Quality measurement, SGR, VBM
Apr 15, 2015
There are dozens of ways to take stock of the Affordable Care Act as it turns 5 years old today. According to HHS statistics:
- 16.4 million more people with health insurance, lowering the uninsured rate by 35 percent.
- $9 billion saved because of the law’s requirement that insurance companies spend at least 80 cents of every dollar on actual care instead of overhead, marketing, and profits
- $15 billion less spent on prescription drugs by some 10 million Medicare beneficiaries because of expanded drug coverage under Medicare Part D
- Significantly more labor market flexibility as consumers gained access to good coverage outside the workplace
Impressive. But the real surprise after five years is that the ACA may actually be helping to substantially lower the trajectory of healthcare spending. That was far from a certain outcome. Dubbed the Patient Protection and Affordable Care Act for public relations purposes, there were, in fact, no iron clad, accountable provisions that would in the long run assure that health insurance or care overall would become “affordable.”
ACA supporters appear to have lucked out—so far. Or maybe, just maybe, it wasn’t luck at all but a well-placed faith that the balance of regulation and marketplace competition that the law wove together was the right way to go.
To be sure, other forces such as the recession were in play—accounting for as much as half of the reduction in spending growth since 2010. But as the ACA is once again under threat in the Supreme Court and as relentless Republican opposition continues, it’s worth paying close attention to new forecasts from the likes of the Congressional Budget Office (CBO) and the actuaries at the Centers for Medicare and Medicare Services (CMS).
The ACA is driving changes in 17 percent of the U.S. economy that, if reversed or interrupted, would have profound impact on federal, state, business, and family budgets. A quick look at some important numbers follows:
Continue reading “Happy 5th Birthday, ACA”
Filed Under: THCB
Tagged: ACA, CBO, CMS, health reform, Medicare, spending
Mar 23, 2015
The U.S. Department of Health and Human Services’ recent announcement to move the Medicare program toward value-based payments is among the most promising recent developments in health care.
While changing the way we pay for care will not be easy, we believe that shifting away from fee-for-service to value-based payments could be a catalyst to a better, more affordable health care system in our country.
Three Benefits of Paying for Quality
There are numerous potential benefits to paying for quality rather than quantity, including the three we want to focus on today.
- We believe this payment shift has the potential to accelerate progress toward achieving the Triple Aim – defined as better individual care, better population care, and lower cost.
- We believe the payment shift by Medicare will accelerate the transition to value-based payments among commercial insurers – a major benefit to employers in terms of improved health for employees and greater affordability.
- We believe value-based payments have the potential to help slow – and possibly reverse – the epidemic of physician burnout in the United States, particularly among primary care doctors. Continue reading “Value-Based Reform”
Filed Under: OP-ED, THCB
Tagged: Employers, Fee-for-service, Medicare, payment reform, physician burnout, Quality, Triple Aim
Mar 2, 2015
In Washington, sometimes the most significant developments quietly creep up on you. No epic debate or triumphant bill-signing ceremony, but rather a collection of seemingly small events begin to tip the scales.
That’s what is happening today with telehealth. Almost under the radar, federal and state officials have been giving a much-needed push in support of virtual care. Though the technology has long existed, until recently the money had not followed. And sadly in our current fee-for-service healthcare system, little gets done without a payment code, even if it makes eminent medical and economic sense.
Consider some of the recent action. In November, the Department of Agriculture released more than $8.5 million in health-related grants to 31 recipients in rural communities. Many are using the money to purchase telehealth equipment such as high-quality cameras and broadband Internet.
The previous month the federal government issued rules expanding Medicare payment for a range of telehealth services. Caregivers can earn about $42 per month for chronic care management under the new regulations. Seven new procedure codes were also added, covering such services as annual wellness visits and psychotherapy.
And the end-of-year spending bill approved by Congress designates more than $26 million for telemedicine programs largely in rural communities and through the Veteran’s Administration. Continue reading “Tele Taking Off”
Filed Under: Tech, THCB
Tagged: Anti-kickback laws, Ceci Connolly, Doctor on Demand App, Medicare, Teledentistry, Telehealth
Jan 31, 2015
Saturday, the U.S. Senate passed the House-sponsored Omnibus Appropriation Bill that funds the federal government through September 2015. In all likelihood, all eyes weren’t glued to these proceedings, perhaps otherwise attentive to holiday shopping or the events around nationwide protests about policing in our cities.
Healthcare is a huge part of the federal budget: combining spending for Medicare, Medicaid, Children Health Insurance Program (CHIP), military and veterans’ health, Indian Health Services and federal employee health benefits, it represents 35% of the total $3.9 trillion budget. For the decade prior to the economic downturn, total health spending increased 7.2% annually. During the downturn, it slowed to less than 4% but is expected to increase to 6% annually for the decade ahead. That means healthcare spending will be an even bigger part of federal budgets going forward.
Continue reading “The FY15 Budget: There’s More to it Than the Numbers”
Filed Under: THCB
Tagged: FY2015 Budget, Health care spending, Medicaid, Medicare
Dec 16, 2014
My life changed dramatically 18 months ago when I started my new practice. The biggest change personally was a dramatic drop in my income as I built a new business using a model that is fairly new. That’s a tough thing to do with four kids, three of whom were in college last fall. OK, that’s a stupid thing to do, but my stupidity has already been well-established.
Yet even if the income stayed identical to what I earned before the switch, the change in my professional life would have been nearly as dramatic.
- I am no longer focused only on patients in my office.
- I am no longer focused on ICD and CPT codes.
- Saving patients money has become one of my top priorities.
- I feel like my patients trust me more, and see me as an ally.
- Patients accept my recommendations for less care (avoiding unnecessary testing and unnecessary medications) much easier.
- I focus far more on preventing problems or keeping them small.
- I laugh with my patients far more.
- I no longer feel like a Zombie at the end of the day (and I no longer eat brains)
Continue reading “Doctors vs. Zombies”
Filed Under: Physicians, THCB
Tagged: Coding, CPT, ICD-10 codes, Medicare, payors, practice management, Reimbursement, Transaction theory
Jul 16, 2014
Five years ago, my mother needed an orthopedic surgeon for a knee replacement. Unable to find any data, we went with an academic doctor that was recommended to us (she suffered surgical complications). Last month, we were again looking for an orthopedic surgeon- this time hoping that a steroid injection in her spine might allay the need for invasive back surgery.
This time, thanks to a recent data dump from CMS, I was able to analyze some information about Medicare providers in her area and determine the most experienced doctor for the job. Of 453 orthopedic surgeons in Maryland, only a handful had been paid by Medicare for the procedure more than 10 times. The leading surgeon had done 263- as many as the next 10 combined. We figured he might be the best person to go to, and we were right- the procedure went like clockwork.
Had it been a month prior to the CMS data release, I wouldn’t have had the data at my fingertips. And I certainly wouldn’t have found the most experienced hand in less than 10 minutes.
It’s been a couple of months since the release of Medicare data by the Centers for Medicare and Medicaid (CMS) on the volume and cost of services billed by healthcare providers, and despite the whiff of scandal surrounding the highest paid providers (including the now-famous Florida ophthalmologist that received $21 million) the analyses so far have been somewhat unsurprising. This week, coinciding with the fifth Health DataPalooza, is a good time to take stock of the utility of this data, its limitations, and what the future may hold.
Continue reading “10 Things You Can Do With CMS Data”
Filed Under: Tech, THCB
Tagged: CMS, Data Dump, Mash ups, Medicare, Outliers, Practice patterns, Quality, specialists, Trending, Value
Jun 9, 2014
Late last Friday after the financial markets closed, the Centers for Medicare and Medicaid Services (CMS) issued its annual notice of 2015 payments to private insurers who sell Medicare Advantage plans to seniors. Its determination that a 3.55% cut is in order was spelled out in a complicated 148-page explanation of its methodology.
The net impact of changes to “coding intensity” adjusted for geographic variation essentially means insurance companies would see a 1.9% cut in their payments per Avalere’s calculations.
But there’s more to the story than the Medicare Advantage payment adjustment. The difference between last year’s Round One rate negotiation and this year’s Round Two is significant.
Medicare Advantage (MA) plans enroll 28% of seniors. It is popular: enrollment increased from 5.3 million in 20104 to 16 million today—a 9% increase last year alone. MA plans are required to offer a benefit “package” at least equal to Medicare’s covering everything Medicare allows, but not necessarily in the same way.
Continue reading “Medicare Advantage Round Two: Negotiation Will Not Be the Same”
Filed Under: The Business of Health Care
Tagged: CMS, Health Plans, Insurers, Medicare, Medicare Advantage, Paul Keckley
Feb 28, 2014
Partisan gridlock in Washington regarding health policy has been so pervasive and bitter that any bipartisan co-operation on any important health issue should be applauded by a frustrated public.
That is why the emerging bipartisan compromise regarding the fifteen-year long policy embarrassment known as the Sustainable Growth Rate (SGR) problem needs to be taken seriously.
Remarkably similar solutions — a new hybrid physician “value-based” payment methodology — have emerged from three of the four key committees in Congress, and seemingly the only stumbling block is finding the $115-120 billion to pay for it.
Moreover, key physician interest groups, including the American Medical Association, appear to have signed off on this approach.
This makes it all the more troubling that the approach taken is unsound health policy that will damage practicing physicians in diverse settings: private practice, medical school practice plans, and hospital employment.
This is because the proposed legislation casts in concrete an almost laughably complex and expensive clinical record-keeping regime, while preserving the very volume-enhancing features of fee-for-service payment that caused the SGR problem in the first place. The cure is actually worse, and potentially more expensive, that the disease we have now.
The SGR fix would basically freeze or severely limit future physician fee updates for Medicare Part B (a serious problem for primary care), while permitting physicians to earn modest “value-based” bonuses if they can document quality measure attainment, cost reductions, participation in alternative payment schemes, practice enhancement activities, or meaningful use of EHRs.
Physicians who meet all these standards could expect to supplement their existing Part B fee by about 4 percent in 2016, going to 10 percent in 2020, with the aggregate bonuses subtracted from the pool of total Part B physician payments to preserve budget neutrality. Non-compliant physicians would see corresponding reductions in their updates.
There are sensible opt-outs for physicians who can report in groups, virtual or real, as well as for physicians who participate in as yet unspecified “advanced payment models” (APMs).
Continue reading “Why the SGR Fix Won’t Work and Could Actually Make Things Worse”
Filed Under: Physicians, THCB
Tagged: American Medical Association, Doc Fix, Jeff Goldsmith, Medicare, sustainable growth rate (SGR)
Feb 7, 2014
No-one can say any longer that Senate Republicans are entirely deaf to calls to describe how they would replace the much maligned Affordable Care Act.
This week, three senior GOP senators (Orrin Hatch, Tom Coburn, and Richard Burr) announced their proposed Patient Choice, Affordability, Responsibility, and Empowerment (or Patient CARE) Act. Given that each of this group is a heavyweight mainstream Republican and that Senator Coburn is one of the few physicians in the Congress, the draft Act deserves a serious look.
Although the first part of the draft would repeal the ACA, other parts would continue a number of the ACA’s reforms while introducing some changes in attempts to control costs and reduce the numbers of uninsured, creating a kind of Obamacare Lite.
The draft proposes to continue the ACA’s ban on lifetime insurance caps, its coverage of dependents up to the age of 26, and the ACA’s savings in Medicare costs. It also continues, although in a weaker form, the ACA’s subsidies for low-income individuals and the ban on medical underwriting, and allows states to continue to operate insurance exchanges (although without any federal funding).
On the other hand, the three parts of the ACA that have taken the most heat from Republicans – the individual mandate, the Medicare IPAB, and the expansion of Medicaid eligibility – would all be eliminated.
Continue reading “After Months of Thought Senate Republicans Propose Obamacare Lite”
Filed Under: Uncategorized
Tagged: GOP Repeal, Individual mandate, Insurance, IPAB, Medicaid Expansion, Medicare, Orrin Hatch, Patient CARE Act, Richard Burr, Roger Collier, The ACA, Thomas Coburn
Jan 31, 2014